Wednesday, October 13, 2010

The War Between QALYs and Death Panels

The current issue of the New England Journal of Medicine has an excellent "Perspective" piece by Peter Neumann and Milton Weinstein - "Legislating Against Use of Cost-Effectiveness Informantion." The authors discuss the fact that the health reform bill calls for a Patient Centered Outcomes Research Institute, but specifically forbids it from considering cost per QALY in its work. Here's the gist of their argument:

The antagonism toward costper-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness farther down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints. Although opportunities undoubtedly exist to eliminate health care waste, the best way to improve health and save money at the same time is often to redirect patient care resources from interventions with a high cost per QALY to those with a lower cost per QALY. At a time when health care costs loom as the greatest challenge facing our country’s fiscal well-being, legislating against the use of the standard metric in the field of cost-effectiveness analysis is regrettable.

The contrast between the relatively grown up approach to health policy in the U.K. and the immature head-in-the-sand approach in the U.S. couldn't be more stark. The National Institute for Clinical Excellence makes explicit use of QALYs - value for human beings per dollar spent. We forbid it.

Still, creation of the Outcomes Institute is a step forward. The legislation caved in to the death panel crowd, but simply establishing and funding an outcomes process is a positive step. As Churchill said, "You can always count on Americans to do the right thing - after they have tried everything else."